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New ADA guideline advises against prescribing antibiotics for most dental pain, swelling

October 25, 2019

By Mary Beth Versaci

Antibiotics are not needed to manage most dental pain and intraoral swelling associated with pulpal and periapical infections, according to a new guideline from the American Dental Association published in the November issue of The Journal of the American Dental Association.

2019 November JADA cover
The guideline, "Evidence-Based Clinical Practice Guideline on Antibiotic Use for the Urgent Management of Pulpal- and Periapical-Related Dental Pain and Intraoral Swelling: A Report from the American Dental Association," advises against using antibiotics for most pulpal and periapical conditions and instead recommends only the use of dental treatment and, if needed, over-the-counter pain relievers such as acetaminophen or ibuprofen.

"Antibiotics are, of course, tremendously important medications," said Dr. Peter B. Lockhart, chair of the panel that developed the guideline and research professor at Carolinas Medical Center-Atrium Health. "However, it is vital that we use them wisely so that they continue to be effective when needed to manage an infection."

The panel, which was convened by the ADA Council on Scientific Affairs and worked alongside methodologists in the ADA Center for Evidence-Based Dentistry and ADA Library & Archives, reviewed existing literature on the harms and benefits of antibiotics as treatment for pulpal and periapical conditions, finding the medications may cause significant harm while providing negligible benefits.

Dentists should instead prioritize treatments such as pulpotomy, pulpectomy, nonsurgical root canal treatment or incision and drainage for symptomatic irreversible pulpitis, symptomatic apical periodontitis and localized acute apical abscess in adult patients with normal immune systems, according to the guideline.

If a patient's condition progresses to showing signs or symptoms of systemic involvement, such as fever or malaise, then dentists should prescribe antibiotics, the guideline advises.

"Dental treatment without antibiotics is often sufficient to manage a dental infection, but when it is not available and the patient has signs and symptoms such as fever or swollen lymph nodes, antibiotics may need to be prescribed," Dr. Lockhart said. "But in most cases when adults have a toothache and access to dental treatment, antibiotics may actually do more harm than good."

The ADA's guideline is part of larger efforts across the globe to prevent antibiotics from becoming ineffective in treating bacterial infections, including the U.S. government’s Antimicrobial Resistance Challenge. General and specialty dentists are the third-highest prescribers of antibiotics in all outpatient settings in the U.S., according to the guideline.

To read the guideline in JADA, visit For additional resources, go to

Other articles in the November issue of JADA discuss the characteristics of localized aggressive periodontitis that support its classification as a distinct subcategory of periodontitis, a data-driven method to enhance craniofacial and oral phenotype vocabularies, and breastfeeding's association with reduced pacifier sucking in children.

Every month, JADA articles are published online at in advance of the print publication.